Acute cholecystitis

Acute cholecystitis, sometimes referred to as biliary colic, is an acute inflammation of the gallbladder. It is a major complication and usually arises from gallstones (cholelithiasis) (National Institute for Health and Care Excellence, (NICE), 2021). It is estimated that gallstones affects 5% of adults, although most people never experience symptoms (NICE, 2014).

Acute cholecystitis occurs in around 10-15% of people with gallstones (NICE, 2021). It is most commonly caused by complete obstruction of the cystic duct, which is usually a result of gallstones becoming impacted in the cystic duct or the neck of the gallbladder (Abercrombie, 2023). The obstruction leads to inflammation in the wall of the gallbladder. About 95% of people with acute cholecystitis have gallstones, with the majority being women (Halpin, 2014).

In some cases, cholecystitis is caused by thickening of the bile, secondary to dehydration or the complete lack of bile movement through the gallbladder as a result of trauma or systemic disease. Cholecystitis which is not caused by gallstones is known as acalculous cholecystitis; this has a mortality rate of up to 50% (NICE, 2021) compared to a mortality rate of about 4% in patients with calculous acute cholecystitis.

The people most at risk from acute cholecystitis are

The signs and symptoms of acute cholecystitis include:

• pain and tenderness in the upper right abdominal quadrant – usually sudden onset
• pain in the back – not musculoskeletal
• right shoulder pain (referred pain)
• pain without heartburn and not relieved by defaecation (Hapca et al, 2021)

One additional sign which is shown in patients with cholecystitis but not in patients with gallstones is Murphy’s sign. This is the inhibition of inspiration as a result of pain on palpitation, when the examiner's hand is on the costal margin (NICE, 2021). However, this is usually an unreliable measure in the acutely ill and older patients.

Other signs and symptoms which indicate an individual may have acute cholecystitis include:

• fever – suspected sepsis
• chills
• nausea and vomiting
• weight loss
• jaundice (about 10% of cases)
• dark urine
• pale stools (NICE, 2014; 2015; Redfern and Mortimore, 2019; NICE 2021; Abercrombie 2023)

Around half of all people who experience an episode of biliary pain will have a repeat episode in the year and many will have a recent history of being unwell, so

Clinicians should suspect acute cholecystitis in people presenting with acute constant pain and tenderness with guarding of the upper right abdominal quadrant. The suspicion may be raised in people with increased risk factors, such as:

• older people
• women
• people with obesity
• people who have a low-fibre diet (NICE, 2021)

Acalculous acute cholecystitis is more prevalent in people who are acutely unwell and might be suspected in people presenting with sepsis, extensive trauma and prolonged starvation. Groups who are more at risk of acalculous acute cholecystitis include people:

• living with diabetes
• with cardiovascular disease
• with HIV
• with Epstein-Barr virus
• taking certain medication (eg ciclosporin) (Balmadrid, 2018).

Ultrasound imaging can help with diagnosis, as it can identify both gallstones and the acute pathological changes affecting the gallbladder (NICE, 2014; 2015). NICE (2014) also advise that magnetic resonance cholangiopancreatography should be performed if ultrasound shows bile duct dilation and/or liver function tests that

The management of acute cholecystitis will depend on the aetiology and severity of the disease.

The treatment of choice for acute cholecystitis is an early cholecystectomy (removal of the gallbladder), which may be done laparoscopically (Halpin, 2014). Laparoscopic surgery should usually be performed within 7 days of diagnosis of acute cholecystitis to help avoid complications, such as infection and inflammation (NICE, 2014; 2015). When this is not possible, it is advised to wait for over 4 weeks until the acute episode has subsided following medical management (NICE, 2015).

In some cases, laparoscopic surgery for gallbladder removal may need to be converted to open, laparotomy surgery because of certain complications, such as bleeding. In other cases, such as when the patient has a fistula from the gallbladder to the bile duct, laparotomy is the recommended surgical approach (Halpin, 2014).

NICE (2015) also identify endoscopic retrograde cholangiopancreatography, within 72 hours of diagnosis,

Abercrombie J. Acute cholecystitis. 2023. https://bestpractice.bmj.com/topics/en-gb/3000084 (accessed 9 November 2023)

Balmadrid B. Recent advances in management of acalculous cholecystitis. 2018;7:F1000Res. https://doi.org/10.12688/f1000research 

Halpin V. Acute Cholecystitis. BMJ Clin Evidence. 2014:0411.

Madden AM, Trivedi D, Smeeton NC, Culkin A. Modified dietary fat intake for treatment of gallstone disease. Cochrane Database Syst Rev. 2021;6. https://doi.org/10.1002/14651858.CD012608.pub2 

National Institute for Health and Care Excellence (NICE). Gallstone disease: diagnosis and management. 2014. https://www.nice.org.uk/guidance/cg188 (accessed 9 November 2023)

National Institute for Health and Care Excellence (NICE). Gallstone disease. 2015. https://www.nice.org.uk/guidance/qs104/chapter/quality-statement-1-acute-cholecystitis (accessed 9 November 2023)

National Institute for Health and Care Excellence (NICE). Cholecystitis – acute. 2021. https://cks.nice.org.uk/topics/cholecystitis-acute/ (accessed 9 November 2023)

Redfern V, Mortimore G. Right hypochondrial pain leading to diagnosis of cholestatic jaundice and cholecystitis: a review and case study. Gastrointestinal Nursing. 2019;17(5): 32-41. https://doi.org/10.12968/gasn.2019.17.5.32